BlueCross
BlueShield of
Massachusetts
Visits, Subscriber and
Dependent v1.3
Visits Cancel, Subscriber
and Dependent v1.2
BlueCross BlueShield of Massachusetts Visits and Visits Cancel
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Emdeonis not liable for any losses or damages that result from the use of this material, including loss of profit or indirect, special, or consequential damages.
BlueCross BlueShield of Massachusetts Visits and Visits Cancel Table of Contents
Table of Contents
Overview --- 1
About the Transaction --- 1
Customer Support --- 1 Requests --- 2 Search Types --- 2 Visits --- 2 Visits Cancel --- 2 Cascade Sequence --- 3 Input Prompts --- 3 Account # --- 3 Amount --- 3 Card Suffix --- 3 Date of Birth --- 4 Date of Service --- 4 Diagnosis Code --- 4 ID Card # --- 4 Member ID --- 4 Provider ID --- 4 Ref/Auth # --- 4
Req Prov Type --- 4
Service Type --- 5
Responses --- 6
About Your Responses --- 6
Status --- 6
Indicators --- 6
Input and Response Information --- 7
Transaction Information --- 7 Information Source --- 8 Information Receiver --- 8 Subscriber --- 8 Eligibility/Benefit --- 8 Error Messages --- 9 Values --- 10 Insurance Types --- 10 Index --- 12
BlueCross BlueShield of Massachusetts Visits and Visits Cancel Overview
Overview
About the Transaction
The BlueCross BlueShield of Massachusetts (BCBSMA) Visits transaction allows you to record a patient encounter. When you use this transaction to record a managed care patient’s visit, BCBSMA will deduct one visit from any applicable referral or authorization.
Note: Recording a BCBSMA managed care patient’s visit in the physician’s office setting will guarantee that the matching claim will not reject for eligibility reasons.
A BCBSMA Visits Cancel transaction allows you to cancel a previously-submitted visit transaction. Visits and Visits Cancel transactions are available for BCBSMA patients only.
Special Considerations
A Visits Cancel transaction must be run the same day as the Visits transaction.
Customer Support
Emdeon Customer Support
800.333.0263
BlueCross BlueShield of Massachusetts Visits and Visits Cancel Requests
Requests
Search Types
Visits
ID Card• The provider ID of the inquiring provider.
• The provider type.
• The ID card number (read from the patient’s card).
• The card suffix (read from the patient’s card).
• The date of birth (optional)
• The date of service.
• The service type.
• The diagnosis code (for emergency visits).
• The referral number (optional).
ID/DOB
• The provider ID of the inquiring provider.
• The provider type.
• The member ID.
• The date of birth (optional for 11-digit member IDs).
• The date of service.
• The service type.
• The diagnosis code (for emergency visits).
• The referral number (optional).
Visits Cancel
ID Card
• The provider ID of the inquiring provider.
• The provider type.
• The ID card number (read from the patient’s card).
• The card suffix (read from the patient’s card).
• The date of birth (optional).
• The date of service.
• The service type.
BlueCross BlueShield of Massachusetts Visits and Visits Cancel Requests
ID/DOB
• The provider ID of the inquiring provider.
• The provider type.
• The member ID.
• The date of birth (optional for 11-digit member IDs).
• The date of service.
• The service type.
• The authorization number.
Cascade Sequence
Visits 1. ID Card 2. ID/DOB Visits Cancel 1. ID Card 2. ID/DOB What is Cascading?Cascading refers to the capability of the software to execute multiple searches automatically when a single search does not find the patient’s record, or receives an error with a Retry status.
To enable cascading in a transaction, you must enter data for more than one search type. In this case, the software will continue to cascade until one of the following occurs:
• The patient’s record is found, or a valid non-error response is received (Closed status)
• All available search types have been exhausted
• An error is received with an Error status
Input Prompts
Prompts are listed in alphabetical order.
Account #
Requirement: Optional.
The patient’s account number. For your internal use only (not sent to the payer).
Amount
Requirement: Optional.
The amount of the claim. For your internal use only (not sent to the payer).
Card Suffix
Used in: Visits and Visits Cancel card number searches. Requirement: Required.
The two-digit member ID suffix. This information is read automatically when you swipe the patient's card.
BlueCross BlueShield of Massachusetts Visits and Visits Cancel Requests
Date of Birth
Requirement: Member ID searches: Required for FEP members and nine-digit member IDs (three-character prefix plus nine digits), optional for eleven-digit member IDs.
Hard card searches: Optional.
The patient’s date of birth, in MMDDCCYY format.
Date of Service
Requirement: Required.
The date of service, in MMDDYY or MMDDCCYY format.
Diagnosis Code
Used in: Visits transactions only.
Requirement: Required only for service type 86 (Emergency Services); otherwise, leave blank. The ICD-9-CM or ICD-10-CM diagnosis code.
ID Card #
Used in: Visits and Visits Cancel card number searches. Requirement: Required.
The identification number from the patient's card. This information is read automatically when you swipe the patient's card.
Member ID
Used in: Visits and Visits Cancel member ID searches. Requirement: Required.
The three-character prefix and nine- or eleven-digit member ID from the patient’s hard card.
For FEP members, do not enter the three-character prefix; enter R plus the eight-digit member number. Note: Each BCBSMA patient has his or her own unique member ID.
Provider ID
Requirement: Required.
The provider ID of the inquiring provider.
Ref/Auth #
Used in: Visits Cancel transactions only. Requirement: Required.
The reference number assigned to the visit (use the number in TRACE 3 of the Visits response).
Req Prov Type
Used in: Visits transactions only. Requirement: Required.
BlueCross BlueShield of Massachusetts Visits and Visits Cancel Requests
Service Type
Requirement: Required.
BlueCross BlueShield of Massachusetts Visits and Visits Cancel Responses
Responses
About Your Responses
All of the items described in the following response explanation may not appear in every response. Payers typically return only the information that is applicable to your query.
If the payer does not return a particular piece or section of information in a specific response, the headings for that information will not print. Items will shift position to fill the vacancy.
Your username appears in the upper left corner of the response. See your product User’s Guide for information about creating usernames.
Additional Reference Documents
More information about your response can be found in the following documents:
• PC-Standard-Eligibility-Response-Dictionary.pdf - gives a more detailed description of data fields returned in the standard Emdeon response.
• Dictionary-of-Transaction-Error-Messages.pdf – a complete dictionary of error messages.
• Common Response Abbreviations.pdf – common abbreviations used in the standard Emdeon response, along with their full description.
These documents are available on your installation CD, and on the Web at: www.emdeon.com/resourcelibrary/#84
Note: The above documents are in Portable Document Format (.pdf). You must have the Adobe®
Acrobat® Reader to view this document. If you do not have the Reader, you can download it for free at
www.adobe.com.
Status
Closed
Emdeon received a valid response. Read your response for clarification. Retry
Emdeon did not receive a valid response. Read the message in the response for clarification. Error
A communications-related error or error of greater severity occurred. Read the message in the response for clarification.
Indicators
This information appears on the top of the report. The indicators show the following: Benefit
Indicates the presence or type of benefit information in the response. Y = Benefit information exists
N = No benefit information exists
P = Pending
BlueCross BlueShield of Massachusetts Visits and Visits Cancel Responses S = Spenddown
Other Payer
Indicates the patient’s Other Payer coverage. Y = Patient has Other Payer coverage.
NA = Unable to determine if Other/Additional Payer information is present in the response from the payer. Medicare
Indicates the patient’s Medicare coverage. A = Patient has Medicare Part A coverage.
B = Patient has Medicare Part B coverage.
A&B = Patient has Medicare Parts A and B coverage.
NA = Unable to determine if Medicare information is present in the response from the payer.
Input and Response Information
The input area shows the data you sent in the request. For some of the input fields, the response area displays what the payer actually has on file. This arrangement enables you to verify what you entered against what is on file.
Depending on your software product and report settings, response information fields can appear in one of two locations:
• They can appear in a column to the right of the input fields.
• They can appear beneath the input fields, with the heading (On File).
An asterisk to the left of an input field indicates that the mirrored response data did not match your input data.
The following response fields are displayed: The patient’s BCBSMA member ID.
The patient’s date of birth.
Transaction Information
The Transaction Information section returns reference information for this particular transaction, such as:
The Submit ID used for tracking.
The date and time when the transaction was created. Benefit Indicator:
Y = Benefit information exists. N = No benefit information exists. P = Pending.
Q = QMB. S = Spenddown. Medicare Indicator:
A = Patient has Medicare Part A coverage. B = Patient has Medicare Part B coverage.
BlueCross BlueShield of Massachusetts Visits and Visits Cancel Responses NA = Unable to determine Medicare coverage.
Other Payer Indicator:
Y = Patient has other payer coverage.
NA = Unable to determine other payer coverage.
Information Source
Information about the payer, such as primary ID and name.
Information Receiver
Information about the requesting provider, such as primary ID and name.
Subscriber
Information about the subscriber, or the patient, when the patient is the subscriber. Includes: The transaction audit (trace) numbers and origins.
The subscriber’s primary ID. Demographic information, such as:
Last, first, middle name Prefix and suffix
Date of birth Gender Address Student status Handicap indicator Birth sequence
Whether any identifying elements for the subscriber have changed from those submitted in the request (Change).
Additional identification numbers other than the primary ID.
Eligibility or benefit dates. Dates can also appear in the Eligibility/Benefit section.
Eligibility/Benefit
Each Eligibility/Benefit section gives details about the patient’s eligibility status and other types of benefits. There can be several Eligibility/Benefit sections. Information includes:
Eligibility Type: Identifies the type of information to which this section applies. The following types can appear:
Actv Cvg Inactv
Inactv – Pend Elig Updte Co-Pay
Bene Descrip PCP
BlueCross BlueShield of Massachusetts Visits and Visits Cancel Responses Coverage type.
Service types.
Applicable dollar amount or percentage.
Insurance type (see “Insurance Types” on page 10). Plan coverage information.
Benefit period. Benefit quantity.
Authorization or certification required. In-network indicator.
Product or service ID. Procedure Modifiers.
Health care service delivery details. Additional identifiers.
Benefit-specific eligibility dates. Limitations.
Information used to determine eligibility.
Benefit-related entity and entity contact information.
For a complete description of the abbreviations appearing in this section, see Common Response Abbreviations.pdf on your installation CD and on the Web at
www.emdeon.com/resourcelibrary/#84
Error Messages
Transaction-related error messages begin with CL, HT, RH, or another alphabetic prefix, followed by a number and a line or so of text.
For a comprehensive description of all error messages, see the document Dictionary of Transaction Error Messages.
This document is available on your installation CD, and on the Web at: www.emdeon.com/resourcelibrary/#84
BlueCross BlueShield of Massachusetts Visits and Visits Cancel Values
Values
Insurance Types
The payer can return any of the values listed below.
Value in Response Description Mcare 2ndary Working Aged
Beneficiary or Spouse with EGHP Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan Mcare 2ndary ESRD Beneficiary in the
12 mo coordination period with an EGHP
Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer group health plan
Mare 2ndary, No-fault Ins including
Auto is Primary Medicare Secondary, No-fault Insurance including Auto is Primary Mcare 2ndary Work Comp Medicare Secondary Workers Compensation
Mcare 2ndary PHS or Other Federal
Agency Medicare Secondary Public Health Service (PHS) or Other Federal Agency Mcare 2ndary Black Lung Medicare Secondary Black Lung
Mcare 2ndary Vets Admin Medicare Secondary Veterans Administration Mcare 2ndary Disabled Beneficiary
Under Age 65 with LGHP Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) Mcare 2ndary, Other Liability Ins is
Primary Medicare Secondary, Other Liability Insurance is Primary Auto Ins Pol Auto Insurance Policy
Comm Commercial
COBRA Consolidated Omnibus Budget Reconciliation Act (COBRA) Mcare Conditionally Primary Medicare Conditionally Primary
Disability Disability
Disability Benes Disability Benefits
Exclusive Provider Organization Exclusive Provider Organization Fam or Friends Family or Friends
Grp Pol Group Policy
HMO Health Maintenance Organization (HMO)
HMO – Mcare Risk Health Maintenance Organization (HMO) – Medicare Risk Spcl Low Income Medicare Beneficiary Special Low Income Medicare Beneficiary
Indemnity Indemnity
Indiv Pol Individual Policy
LTC Long Term Care
Long Term Pol Long Term Policy
Life Ins Life Insurance
Litigation Litigation
Mcare A Medicare Part A
BlueCross BlueShield of Massachusetts Visits and Visits Cancel Values Value in Response Description
Mgap A Medigap Part A
Mgap B Medigap Part B
Mcare Primary Medicare Primary
Other Other
Property Ins – Personal Property Insurance – Personal
Personal Personal
Personal Payment (Cash - No Ins) Personal Payment (Cash - No Insurance) PPO Preferred Provider Organization (PPO)
POS Point of Service (POS)
QMB Qualified Medicare Beneficiary
Property Ins – Real Property Insurance – Real Supplemental Pol Supplemental Policy
TEFRA Tax Equity Fiscal Responsibility Act (TEFRA)
Work Comp Workers Compensation
BlueCross BlueShield of Massachusetts Visits and Visits Cancel Index
Index
A
About the Transaction, 1 About Your Responses, 6 Account #, 3 Amount, 3
B
Benefit, 6C
Card Suffix, 3 Cascade Sequence, 3 Closed, 6 Customer Support, 1D
Date of Birth, 4 Date of Service, 4 Diagnosis Code, 4E
Eligibility/Benefit, 8Emdeon Customer Support, 1 Error, 6 Error Messages, 9
I
ID Card, 2 ID Card #, 4 ID/DOB, 2, 3 Indicators, 6 Information Receiver, 8 Information Source, 8Input and Response Information, 7 Input Prompts, 3 Insurance Types, 10
M
Medicare, 7 Member ID, 4O
Other Payer, 7P
Provider ID, 4R
Ref/Auth #, 4 Req Prov Type, 4 Retry, 6S
Search Types, 2 Service Type, 5 Special Considerations, 1 Status, 6 Subscriber, 8T
Transaction Information, 7V
Visits, 2 Visits Cancel, 2W
What is Cascading?, 33055 Lebanon Pike, Suite 1000 Nashville, TN 37214-2230 877.EMDEON.6 (877.363.3666) www.emdeon.com Emdeon is a leading provider of revenue and payment cycle management and clinical
information exchange solutions, connecting payers, providers, and patients in the U.S. healthcare system.
For more information, visit www.emdeon.com.
